incomplete and of extremely poor quality
I am left wondering why, in this day and age when we are so focused on governance and when this Government have put so much effort into obliging doctors to do governance, it is felt that that governance does not necessarily extend to the Department of Health.
In governance, one must ensure that one measures what one does, that one audits everything that one does and that one looks back to try to determine how one might do things better. In this respect, this Government, pretty well by their own admission, have simply not bothered to collect the kind of data that would enable one to do that kind of auditing exercise. Such an exercise would enable one to compare and contrast ISTCs, one with another, the effectiveness of private sector providers, one with another, and it would allow comparisons to be made with the mainstream NHS.
That is a serious omission. It mirrors omissions of a similar sort in public health. We shall be debating the alcohol harm reduction strategy on Tuesday. Its first phase has not been assessed in any meaningful way, so how on earth can we go on to the second phase? In respect of modernising medical careers and MTAS, it is clear from the Health Secretarys hesitant response to questions put by my hon. Friend the Member for South Cambridgeshire about quality assurance that little of it was built in to that adventure. I suspect that that is part of the problem.
Both the Health Committee and the Government said that organisations such as the British Orthopaedic Association have been alarmist in their assessment of poor quality, but the Government cannot say that such organisations of professionals in the field are being alarmist if they have not acquired the data to refute the allegations. I am afraid that the Government have done themselves no good in failing to acquire that data.
Dr. Murrison: We must give the British Orthopaedic Association and the other professionals some credit for being on the ground. They are the people who see the complications. The Health Committee Chairman scoffs, but when I am faced with a consultant orthopaedic surgeon who has seen the end results of complications that he attributes to ISTCs, I take note of that. I do not make a judgment on whether the British Orthopaedic Association or the Government are correct in asserting that ISTCs are doing a better, worse or the same sort of job as the NHS, but it is wrong to ignore what is admittedly anecdote from professionals about what they see going on. What are they supposed do to? Are they supposed to throw up their hands and say, We are seeing this, but we are not going to tell you? I think not.
Mr. Barron: Witnesses made anecdotal allegations with no evidence whatever, and we asked them about that not on just one occasion, but on several occasions, and when they sat in front of us giving evidence. They could not even back up evidence that they had put on websites. The hon. Gentleman is taking one side.
While we were critical of the BOA, I thought we took a steady line, because we did not say that it was not telling the truth. We said that there was no evidence for what it was saying. How can one side be accepted without the evidence being checked? That is what the hon. Gentleman seems to be doing today.
the number of patients we are seeing with problems resulting from poor surgeryincorrectly inserted prostheses, technical errors and infected joint replacementsis too great.
have been asked to carry out joint replacement operations that they have never seen or done before.
It is quite clear that this has occurred with inadequate training of both the surgeons and the operating theatre staff and as a consequence there have been several serious errorsjoint replacements put in without bone cement when bone cement was essential for that joint replacement, the use of the incorrect size heads...for a hip joint replacements, etc.
Professor Wallace is not in the business of systematically analysing all the cases that have been done in ISTCs. He cannot do that, because he does not have the resourcesnor does the British Orthopaedic Associationbut he is reporting what he is finding on the ground. I am no orthopaedic surgeon, but I have hung off the end of a retractor in an orthopaedic operating theatre, as the hon. Member for Dartford will have done, and even with our rudimentary knowledge of orthopaedicsI speak for myself,not the hon. Gentlemanwe know that that is disastrous.
There are many sorts of hip replacement. They are not all the same, and fitting a Charnley or an Exeter requires surgeons to have done a course for them and the team to be familiar with the kit. Professor Wallaces comments have the feeling of truth to me, and I entirely accept them[Interruption.]
The right hon. Gentleman says from a sedentary position that there is no evidence. The evidence is what I want the Department of Health to acquire. That is what it should have done, then the Minister could have provided the evidence and said whether it refuted any allegations that there are problems with ISTCs. We cannot ignore such remarks from the front line, and if we do, we do so at our great peril and with complacency, which is not what our constituents expectmine certainly do not expect that of me.
Although the Liberal Democrats absence has freed up a bit of time for us, the hour is late and I am sure we all want to get away in good time. My hon. Friend the Member for Southend, West (Mr. Amess) made an important point about language proficiency. The international English language testing system does not apply to European economic area doctors, but does to those from outside the EEA. The Committee rightly pointed out that that is inconsistent. It is not acceptable for Ministers to say that it is up to the employing trust to ensure that people are proficient in the English language. The issue is safety-critical, and if we do not require proficiency to be demonstrated by Polish surgeons, but require that from surgeons from India or Pakistan, who in my experience have excellent English of course, what on earth is the point of having the test at all?
Last month, the Prime Minister delivered what we assume will be his last major speech on health care to the Kings Fund. The funds chief executive pointed out that the success of the reforms will be measured by their sustainability. The Prime Minister did not disagree, and I should be interested to know whether the Minister agrees or disagrees with that assertion. For example, how sustainable does he believe independent sector treatment centres will be, particularly phase 2?
The Committee heard that of the 31 schemes proposed under phase 2, seven will not go ahead. I should be interested to know from the Minister why that is, and why the strategic health authorities that are responsible for the seven schemes will, nevertheless, be obliged to make independent provision by other means? We seem to be going back to Sir Nigel Crisps assertion at the beginning of last year that 10 per cent. of deliverables should be forthcoming from the independent sector.
As I have made clear, I have no problem with involving any provider if it is beneficial to NHS patients, but it is strange that we should insist on private provision, and particularly a certain proportion of service delivery being provided from the independent sector. Why have primary care trusts been bullied into accepting independent sector treatment centres when the Department of Health makes so much about local decision making.
imposed through private, informal methods which included threats and bullying.
The Governments response does not rule out take or pay, and I should be grateful if the Minister would say what he would rule in and what is to replace take or pay, or how take or pay might be modified in phase 2 to make it more acceptable. One thing is for suretake or pay has resulted in a huge waste under phase 1. Page 13 of the Governments response says:
we do not expect to pay the same premium as in wave 1.
It was a good question, which resulted in the Minister placing in the Library a list of ISTCs on which decisions are outstanding. I have a copy of the list in front of me, but it needs updating, because the Nuffield groups project for the west midlands has apparently been cancelled. The Nuffield group has pulled out, citing costs and delays, although we understand today that the BUPA contract for the north-west has been signed off.
I should be grateful if the Minister could say why there appears to be such a delay in signing off the various contracts in the document that he placed in the Library. Has there been or is there likely to be a last-minute rush to sign contracts, given todays momentous events? I am not talking about the Bank of England raising interest rates. How far is the Treasury driving the situation, and can the delay be attributed to the Chancellors attitude to the NHS or desire to placate the service?
Finally, I should like to know the cost of cancelling any projects listed in the document that the Minister placed in the Library on 24 April. Has he, or have any of his officials, been asked to prepare an account of them? I hope that he will be able to answer that question. He can be assured that if he does not answer it directly, I shall press him further.
The Minister of State, Department of Health (Andy Burnham): I thank all right hon. and hon. Members who have contributed to the debate. They are an eminent gathering of health policy experts, and we have had an extremely high-quality debate.
I thank my right hon. Friend the Member for Rother Valley (Mr. Barron) for the measured and balanced way in which he introduced his remarks, and for his leadership of the report by the Select Committee on Health. It has made a timely contribution to the debate about independent sector treatment centres and, more widely, the changing nature of the relationship between the NHS and the private sector. The reports content and its analysis of the changing situation were of particular value.
I hope to reassure the hon. Member for Southend, West (Mr. Amess)I call him my hon. Friendthat far from not taking the recommendations seriously, we have paid careful attention to them. I can point to changes that have since taken place, particularly on two issuesadditionality and trainingthat many Members have raised this afternoon. I shall turn to those points during my remarks.
If I may, I shall begin with a point about perspective. There is often a great deal of hot air vented and ink spilled on the subject, but it is important to remember that by the end of the decade under the current ISTC programme, about 5 per cent. of NHS elective activity will be carried out in the independent sector. We must place the issue in perspective and consider the huge range of work that goes on in our national health service.
On another point of context, last year £216 million was spent on procedures through centrally arranged procurements, compared with the £80 billion-plus that was spent in the national health service. I am not trying to minimise the issues that we are here to discuss, but it is an important point of context.
I am disappointed that my hon. Friend the Member for Pendle (Mr. Prentice) has not stayed for the close of this important debate, although I was pleased that he was present earlier. If he had stayed, I should have asked him and others who question the value of the ISTC programme, and more broadly, the Governments work over the past 10 years on reducing waiting times and lists, to consider the individual patient benefit of such work. Too often, we quote the statistics, but there are many examples of lives that have been changed and improved as a result of the action that has been taken. The hon. Member for Westbury (Dr. Murrison) said that today is a day when we look back over the past 10 years, so perhaps he will not mind if I do so, as Ministers are accustomed to do, with a few figures.
In the first quarter of 1997, 284,000 patients were waiting more than six months for in-patient treatment. My hon. Friend the Member for Dartford (Dr. Stoate), who spoke with incredible knowledge about the subject, was absolutely right: such waits were commonplace at the time. If we think about the human cost of that statistic that we throw out, it is enormous. Today, 350 patients are waiting more than six months. In 1997, more than 30,000 people were waiting more than 12 months, and today, no one is waiting longer than 12 months.
I would have said to my hon. Friend the Member for Pendle that opponents of the ISTC programme rarely ask how many patients in the past were forced to go private. We would never have known about such spend in the private sector, because patients had to fork out for it out of their own pockets. We all know that that is what happened to many people. They were left in such a position when NHS waiting lists were that length, and they were forced to dig into their own pocketstheir own savingsto obtain their operation.
I shall argue that, because of the changed relationship between the NHS and the private sector, in which the two work together for the benefit of not only the NHS but its patients, fewer and fewer people now face that reality. Waiting lists continue to come down, and Government Members should be extremely proud of that fact.
We have achieved a good measure of agreement today about the principles. My hon. Friend the Member for City of York (Hugh Bayley), who asked some very pointed questions about the ISTC programme, began by saying that he did not disagree with the principles, and that was largely the spirit of todays debate.
I shall refresh Members memories about the reasons behind the programme. The Department of Health conducted national capacity planning exercises with strategic health authorities in 2002 and 2004. Through those exercises, SHAs estimated the additional capacity in elective treatment and diagnostics that was required to meet key public service agreement waiting times targets, and they identified how much of that capacity would need to be sourced from the independent sector.
The capacity planning outcomes provided the basis for the first wave of national procurements of elective and diagnostics capacity from the independent sector. The procurement process was designed to allow the independent sector to work within local health care economies to provide solutions that met local requirements.
The specific aims, as the hon. Member for Southend, West said, were to help to provide the capacity needed to deliver swift access to the system for NHS patients, thus reducing waiting lists and times; to support the implementation of patient choice; to stimulate innovative models of service delivery and drive up productivity; to bring down the cost to the NHS of spot purchasing; and to introduce choice and contestability between providers of health care services for NHS patients in order to drive improvement in quality and efficiency throughout all providers.
The first independent sector treatment centre opened in October 2003, and 23 ISTCs are now delivering services to NHS patients. At the end of February, ISTCs had provided more than 110,000 elective procedures for NHS patients, and independent sector contracts had delivered more than 280,000 diagnostic tests. There was additional procurement on top of the ISTC programme, so altogether, centrally procured independent sector schemes have delivered well over 500,000 procedures, diagnostic tests and episodes of care for NHS patients.
The hon. Member for Wyre Forest (Dr. Taylor) asked me to provide him with an update. The figure stood at 300,000 in October 2006 when the Government responded to the Committees report. It is a measure of how much more the independent sector has contributed in that time. Utilisation of the wave 1 ISTC contracts is high and risingat 92 per cent. in February 2007. Cumulatively, that represents 85 per cent. overall to March 2007, as has been mentioned. Patient satisfaction is also high, and was measured to be 97 per cent. across wave 1 schemes in March 2007.
Colleagues have made some extremely high-quality points and I now want to go into the detail of those. My right hon. Friend the Member for Rother Valley, the Chairman of the Committee, spoke about whether there was any evidence of capacity planning and whether the programme had been thought through sufficiently. I assure him that the figures across the wave 1 schemes show high utilisation rates, as ISTCs bed down in their local health care economies. In some cases the utilisation rate is higher than the figures that I have just given, and in one or two cases it is almost 100 per cent. That suggests to me that the exercise conducted by the Department has shown that that capacity both was needed and is being used.
I understand entirely the points that my hon. Friend the Member for Staffordshire, Moorlands (Charlotte Atkins) made. The experience from other parts of the countryI include Greater Manchester in that, and the surgical centre in Trafford, which was one of the
early schemes and serves my constituencyis that questions will be asked in the early days of any ISTC, as the local health economy gets used to working with a new provider in the locality. However, as time progresses those issues are addressed and there is better integration between the NHS locally and the ISTC. The figure that I have for utilisation of the ISTC to which my hon. Friend referred is 75 per cent. for April and May this year, showing some progress from the figures that she quoted.
My right hon. Friend the Member for Rother Valley referred to training and the quality of the data. I shall come to those issues in the meat of my remarks. He also asked about the size of phase 2, which I shall address, too. However, I want first to address the issue of value for money, which a number of hon. Members raised, including my hon. Friend the Member for Pendle in an intervention. It is important to remember that the NHS has always procured services from the independent sector. The difference now is that we are doing so rationally, within clear regulatory and financial frameworks, for the benefit of all of us who use the NHS.
Historically, the NHS used the private sector to provide extra capacity, but on an ad hoc, spot purchase basis, often paying more than 40 per cent. above the cost of the same procedure as performed by itself. As the Committees report rightly noted: